Schizophrenia: issues in the diagnosis of Sz

Question 1

Describe inter-rater reliability

Refer to Beck

Answer 1

this type of reliability occurs when clinicians make identical, independent diagnosis of the SAME patient with schiz. However a study by Beck et al found that when a group of 153 patients with schiz were each assessed by 2 different psychiatrists the diagnosis agreement rate was only 54%. This implies low inter-rater reliability

Question 2

Describe Copelands study (1970)

Answer 2

Copeland gave a description of a patient to 134 US and 194 UK psychiatrists and found that 69% of US psychiatrists diagnosed the patient with scjiz whereas only 2% of UK psychiatrists have the same diagnosis. This shows US clinicians are most likely ti diagnose schiz than UK counterparts

Question 3

Describe co-morbidity as a factor of validity

Answer 3

refers to when more than one disorder or disease exists alongside a primary diagnosis at the same time. For example a person with sciz and personality disorder AT THE SAME TIME. e.g. addiction and sz

Question 4

Describe overlapping symptoms as a factor of validity

Answer 4

No symptoms of sciz are pathognomonic so a valid diagnosis is hard to achieve . In addition, it is estimated that approx 13% of population hear voices but only 1% are diagnosed with schiz (Read et al 2011) This present problems for valid diagnosis

(onlu approx 75% of patients with schiz have hallucinations)

Question 5

Predictive validity

Answer 5

Bleurer
- 20% complete recoi=very
- 20% no recovery
- 40% recover from positive symptoms

Question 6

Copeland

Reliability evaluation (evidence)

Answer 6

In evaluation, a study to highlight problems with inter-rater reliability of the diagnosis of schiz, was conducted by Copeland (1970) which illustrates how the culture of the clinician can damage inter-rater reliability. Copeland gave a description of a patient to 134 US and 194 UK psychiatrists and found 69% of US diagnosed schiz and only 2% of UK. This suggests the reliability of diagnosing schiz is influenced by location and culture of clinician

Question 7

Describe test-retest (external reliability)

Answer 7

Occurs when clinicians make the same schizophrenia diagnosis of the patient on different occassions from the same information. Although clinicians have detailed manuals to use we must accept that patients with schiz and their symptoms change with time (especially negative symptoms, as some psychologists suggest patients withdraw further to cope with the condition) (Read 2004)

Question 8

Reliability evaluation (Read 2004)

Answer 8

In addition, worryingly Read (2004) reported that test-retest analysis is as low as 37% for schiz which is extremely concerning, especialy when we consider the potential false positives and negatives it could create. This suggests that some patients may not be diagnosed when they should and miss out on key medication. Alternatively, it also implies that some patients may receive schiz diagnosis and treatment they don’t need. This could imply that clinicians need to take extra care when diagnosis to avoid false positive/negatives.

Question 9

Reliability evaluation (Farmer 1988)

Answer 9

Nonetheless, a way to improve reliability for diagnosing schiz has been highlighted by Farmer et al. Farmer et al found that a standardised interview technique, known as the present state examination (PSE) increases the reliability of diagnosing schiz bevause it focuses on the freq. and severity of symptoms. This means all patients are asked these things. This suggests that the reliability of diagnosing sciz can be improved by utilising this standardised procedure in diagnosis

Question 10

Reliability of diagnosis evaluation DSM-5 criteria

Answer 10

However, the DSM has also now improved the reliability of diagnosing through revising the criteria. For example, DSM-5 has now stripped the criteria of trying to differentiate between bizarre and non-bizarre delusions from the diagnostic guidelines as it was difficult to complete and led to increased unreliability in diagnosis of schiz. This supports the notion that the DSM had helped to increase the reliability of diagnosis by adapting and changing certain criteria to make diagnosis of schiz more reliable

Question 11

Evaluation of validity of diagnosis- Buckley

Answer 11

P - In evaluation, comorbidity reduces the validity of diagnosis as a clinician could make an inaccurate diagnosis due to the additional disorder.

E - Buckley et al (2009) identified the following comorbid conditions with schizophrenia and argues they could actually be subtypes of schizophrenia. The following was reported with schizophrenia:
15% for panic disorder, 29% with PTSD, 23% and OCD, 50% with depression and 47% with substance abuse.

E - in addition - to complicate matters further, we are unsure as to which condition came first

L - This suggests that..the validity of diagnosing schiz is damaged by the presences of comorbid conditions

Question 12

Evaluation of validity of diagnosis- comorbidity and DSM

Answer 12

Point 2:
P - In further evaluation, we must really re-consider comorbid conditions and schizophrenia.

E - As patients actually suffer from 2 or more mental health states for example, having both schizophrenia and post traumatic stress disorder - both with very specific symptoms and huge amounts of emotional distress

E -Surely that is a UNIQUE CONDITION as opposed to 2 states that coexist and receive
2 separate diagnoses. This has been partly addressed in DSM V, but problems remain with comorbidity and schizophrenia.

L -Therefore….DSM and other manuals will continue to refine diagnostic criteria to tackle the reality of patients suffering from 2 disorders and improve the validity of diagnosing schiz

Question 13

Evaluation of validity of diagnosis- Konstantareas and Hewitt (2001) overlapping symptoms

Answer 13

Point 3
P - An issue with overlapping symptoms is that they can decrease the validity of diagnosis as a clinician may identify symptoms which are common with other disorders.

E - Konstantareas and Hewitt (2001) investigated the symptoms of autistic patients and patients of schizophrenia. They found that…

E - from 14 patients with schiz and 14 with autism- none of the schizophrenic patients had symptoms of autism, but 50% (7) of the autistic patients had symptoms of schizophrenia (particularly negative symptoms

L- This shows support for the fact tha symptom overlap has the potential to damage the validity of diagnosing schiz

Question 14

Evaluation of validity of diagnosis- DSM meeting more than one criteria

Answer 14

Point 4:
P - In conclusion, classification systems such as the DSM can help to improve the validity of diagnosis due to having to meet more than one criteria.

E - For example with schiz, patients do not just need to show 2 symptoms, but also nowadays there is exclusion criteria (e.g. no major depression or manic episodes)

E - AND due to symptoms needing to be present for a certain time frame e.g. symptoms present for a month and disturbance for 6 months

L - This could help to make the diagnosis of schiz more accurate and hopefully avoid misdiagnosis

Question 15

Elaborate: Cultural interpretations of schiz symptoms affect diagnosis of the disorder

Answer 15

some research shows that religious and culrtual groups can have a marked effect on perception of sciz and what can be seen as insane in one culture could be highly desirable in another. This can complicate a valid diagnosis of schiz

Question 16

Elaborate: Negative cultural attitudes to Schiz

Answer 16

Psychological distress and mental health issues attract different levels of stigma in different cultures that will affect diagnosis of schiz. This implies that wihtout being diagnosed people woith sciz will continue to suffer needlesly and unable to access effective therapy. In Japan, sciz is translated to disease of disorganised mind. This means it attracts even more stigma

Question 17

Elaborate: The culture / nationality of the clinician

Answer 17

The actual culture/nationality of the clinicncian can create reliability and validity issues when diagnosing schiz. Although the UK and USA are similar in many respects, the US seems far more likely to diagnose schiz than UK

Question 18

Elaborate: Race discrimination in diagnosing schiz

Answer 18

research has implied that some nationalities and countries have considerably more/less cases of schiz than others. It is suggested some mental health professionals perceive diverse ethnic and cultural groups very differently, and hence discriminate. This implies to avoid misdiagnosis clinicians should be mindful of subtle prejudices.

Blake 1973, 6x more likely yo diagnose schiz if they are african-american compared to white

Question 19

Malgady’s

Evaluation for cultural bias: research

Answer 19

Point 1:
In evaluation, there is research into cultural differences

Malgady’s (1987) research has demonstrated that different cultures interpret symptoms of schiz in very unique ways.

This research showed that in traditional Costa Rican culture hearing voices is interpreted as spirits talking to the individual (a prized abnormality), whereas in the USA the same phenomenon is interpreted as a core symptom of schizophrenia.

This research implies..the cultures we find ourselves in impact on the diagnosis of schizophrenia

Question 20

Evaluation for cultural bias: practical applications

Answer 20

Point 2:

However there are strong practical applications that have come from research into cultural biases of the diagnosis of schizophrenia.

Finding cultural biases allows for training for psychologists into the differences in interpretation and expression of symptoms in cultures. E.g. in Nigeria many patients may claim they have ants running all over their body (tactile hallucination)

This can improve diagnosis because it should make clinicians more sensitive to subtle cultural norms and ways of expressing symptoms

This implies that..by attending to cultural differences we can improve the validity of diagnosis schizophrenia

Question 21

Evaluation for cultural bias: symptom pools

Answer 21

Point 3:

In further evaluation not only does culture impact on diagnosis - it also affects prognosis of schizophrenia

Recent research has actually implied that the recovery form Schiz is much more likely to occur in collectivist cultures compared to individualistic cultures

This could be due to the greater interconnectedness of the these cultures and how when individuals suffer schiz and the accompanying emotional distress, others are more involved in their recovery

This implies that exploring the significance of culture could have an influence on recovery from schiz as well its diagnosis

Question 22

Evaluation for cultural bias: Copeland

Answer 22

There has been further support in research, the culture or nationality of the psychologist or clinician has shown to affect the rate of diagnosis.

Copeland (1971) gave a description of a patient to 134 US and 194 British psychiatrists and found that 69% of the US psychiatrists diagnosed the patient with schizophrenia whereas only 2% of British psychiatrists gave the same diagnosis.

This shows that American clinicians are far more likely to diagnose schizophrenia than their UK counterparts, suggesting the culture of the clinician does impact on diagnosis

Question 23

Evaluating gender bias- Cotton 2009

Answer 23

Point 1:
In evaluation, Cotton’s (2009) research implies women also seem to recover more and suffer less relapse than their male counterparts.
Ignoring these facts would result in gender bias (a BETA BIAS) in clinicians not considering important factors in the diagnosis and recovery from schizophrenia.
This could mean that we miss key factors that are involved in women suffering less rleapse that in theory we could apply to all
This implies that…underreporting of key facts relating to gender and the diagnosis of schiz, not only creates gender bias - but neglects considerations that could help all

Question 24

Evaluating gender bias- Nasser 2002

Answer 24

Point 2
There is also an issue with how research initially only focussed on men and schiz.
Nasser (2002) found that that much of the early research into schizophrenia was conducted with men only. This means lots of research findings concerning treatments and explanations of the disorder may be inappropriate for women.
When research focuses exclusively on men it can be accused of androcentrism and lacks generalisability to target populations.
This suggests…that research into the diagnosis of schiz may suffer from beta bias

Question 25

Evaluating gender bias- Loring and powell 1988

Answer 25

Point 3:
In addition, there may be a gender bias in the diagnosis of schizophrenia due to clinician’s preconceptions as to which gender the disorder is more prevalent in.
Loring and Powell (1988) randomly selected 290 male and female psychiatrists to read two cases. They were then asked to offer there judgments on these individuals using standard diagnostic criteria. When the patient were described as ‘males’ or no information was given about their gender, 56% gave a diagnosis of schizophrenia. However, when the patients were described as ‘females’ only 20% were given a diagnosis of schizophrenia. Interestingly, this gender bias was less prominent with female psychiatrists.

Therefore, this study illustrates the gender biases with regards to schiz. are held by clinicians and how this needs to be addressed in their initial training .

Question 26

Evaluating gender bias- practical applications

Answer 26

Point 4:
However research into gender biases does have good practical applications as it reduces the possibility of diagnoses being made according to gender.
Research can be used to help train psychologists to not misdiagnose females who have schizophrenia symptoms with other disorders associated with females e.g. schizoaffective disorder. This should result in more women receiving the correct diagnosis of schizophrenia, (and subsequent treatment).
It also means that male patients should not be overdiagnosed and should not receive a diagnosis of schizophrenia that is incorrect. The findings from studies such as Loring and Powell can help to show there are biases and improve the validity of the process.
Hence, attending to gender issues in diagnosing schiz could be beneficial for all

Question 27

AO1 for gender bias: Unreported facts in diagnosis of schiz

Answer 27

Men suffer from more severe negative symptoms than women as well as suffering more from substance related disorders. Men are more likely to be involuntarily committed to a psychiatric ward than women as they may be perceived as more of a danger than female patients. Goldstein (1993)

Question 28

AO1 for gender bias: Biased, androcentric research

Answer 28

Since late 19th century, mean have been main ppts which has led to beta bias in schiz.
Some psychologists claim research into schiz has neglected to use many female patients, questioning its usefulness and representativeness.

Question 29

AO1 for gender bias: Underdiagnosis of female patients

Answer 29

Some research has suggested that women do go underdiagnosed in comparison to men. This could have far reaching consequences as it implies many women could be denied access to treatment and have to continue to suffer from debilitating symptoms of schiz